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The following are excerpts from the newsletter

December 1, 2005


December 15, 2005

  • Hazard Alert.

    Another error involving the administration of tetanus toxoid instead of purified protein derivative (PPD) highlights the need for Sanofi Pasteur and FDA to pursue safer labeling and packaging of these products.

  • Misspelling leads to mix-up.

    A handwritten order for ZEGERID (omeprazole) is misspelled and mistaken for ZESTRIL (lisinopril).

  • Keypad “double bounce.”

    The inadvertent registration of the same number twice while programming the rate on pumps has led to overly rapid IV infusions.

  • Fatal injection into the wrong port of a SynchroMed infusion pump.

    Nearly 1 g of morphine was mistakenly injected into the catheter access port of the implanted pump, which led to a patient’s death.

  • Look for the new WHO report.

    The World Health Organization’s World Alliance for Patient Safety recently released Draft Guidelines for Adverse Event Reporting and Learning Systems.

  • IV vincristine survey.

    If you provide oncology services please complete the brief survey at:

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